| Your Full Name |
|
| Home Address |
|
| Street Address |
|
| City |
|
| State |
|
| Zip |
|
| E-Mail |
|
Phone Numbers -
Daytime and Evening |
|
Employer's Name
Number of Employees |
|
Job Title/
Description of Duties |
|
| Date of Hire |
(Hire) |
| Dates During Which You Claim Your Employer was Not Properly Compensating You. |
Date Conduct Began:
Last Date of Conduct:
|
| Nature of Adverse Employment Action Against You. |
|
| Please Explain Why You Believe that Your Employer Has Not Paid You Properly. |
|
1. Please describe the "Who, What, When, Where, Why and How" of the Incidents.
2. Please Identify Any Documents in Support of the Incidents (such as Check Stubs, Time Clock Records, Employee Handbooks, and Communications to or from Your Employer).
2. Please Identify any Witnesses Regarding the Conduct or Actions About Which You are Complaining, as well as What They Witnessed. |
|
Did You Have an Oral or Written Employment Contract About Your Wages? or
Did You Sign an Arbitration Agreement? |
Yes No (Contract)
Yes No (Arbitration) |
Were you Employed Pursuant to a Union Contract (CBA)?
Was There an Employee Handbook? |
Yes No (CBA)
Yes No (Employee Handbook) |
| Date of Birth |
|
| What Damages Have You Suffered to Date? |
Unpaid Wages (E.g., Preparation Before Shift Starts, Wrapping up After Shift Ends, Working Through Lunch, Off the Clock Work, Off The Clock meetings, Off the Clock Trips)
Amount of Unpaid Overtime (E.g., Work Over 8 Hours in One Day, or 40 Hours in One Week, or Double Time after 12 hours in One Day)
Number of Missed 10 Minute Breaks (One Break in the Middle of Every 4 Hours of Work)
Number of Missed, Late or Short Meal Periods (E.g., Late Meal Periods [after 5 hours of work], Meal Periods of Less Than 1/2 Hour, and the Failure to Provide 2nd Meal Periods for Work Shifts Over 10 Hours or 12 Hours)
Were You Paid an Extra Hour of Compensation for Missed Breaks or Meal Periods?
|
| Have You Filed Any Complaint with a Federal or State Agency or Court Concerning Your Wage Claims? |
Yes No (Complaint) |
| If You Have, PleaseState to Which Agenc or Courts? |
|
| When did you file? |
(Date Filed) |
| Have You Received any Award or Ruling? |
|
| When Did You Receive the Award or Ruling? |
(Date Received) |